Marc Hopkinson

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Gateshead Care Home Programme

• Marc Hopkinson

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Our Mission Vision

• Mission
• Working together to improve the health of
  Gateshead
• Vision
• Care for people in a seamless way
• Ensure commissioning is clinically led and driven
  by patients and carer involvement
• Improve the quality of health services

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Needs increasing scale

• Now
• 191,000 population
• 18 over 65 years
• 3.7 over 85 years
• 0.85 living in care homes
• Median length of stay 20 months (23 in Nursing,
  27 in Residential)

• 2030
• 203,000 population
• Aged 65 increase of 1/3 (34,000 45,000)
• Over 85 years - 90 increase (3,900 to 7,500)

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Quality not right now

• Frailty is the issue
• Care is reactive we need specialist proactive
• Variation e.g. multiple practices causes problems
• Communication issues across settings -
  admission/discharge
• Care planning inc advanced care (In and OOH)

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Aim

• To improve the care of patients and families
• through more integrated proactive care

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Objectives

• Improve each care setting and bring them into
• a frailty team
• Increasing skills and understanding in homes.
• Changing reactive primary care delivery to a
  proactive model involving weekly visits by a lead
  GP from the care homes linked practice
• Comprehensive care planning and MDT case
  management led by specialist nurses at the weekly
  ward rounds with ongoing support to homes

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Objectives (Cont)

• Bringing specialists into a virtual team to
  support when needed and improving communication
  between
• Reduce avoidable hospital admissions
• To be cost saving

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Case History Reactive Care

• History
• 96 year old male with COPD from NH, previous
  NOF, non weight bearing, cognitive impairment,
  incontinent of urine
• Presentation
• Urgent care called as unwell sats 69 pulse134
• Admitted 18.00 ambulance MAU
• Assessment
• Diagnosed Urinary sepsis /- chest sepsis
• Intervention
• Antibiotics and fluids
• Review next morning continue treatment but aim to
  keep comfortable
• Next day Liverpool care pathway
• Outcome
• 3.30 AM next day transferred ward 24
• Died 6am following morning in hospital

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Case History Anticipatory Care

• History
• Alzheimers Disease
• Frequent admissions 9,
• Recurrent aspiration pneumonia
• Seizures drowsy on meds
• Presentation
• Drowsy, not eating/drinking, weight loss
• Hypotensive, tachycardia
• Assessment
• Reviewed food/fluid charts long term poor
  intake 500-1000mls/day
• Rapid decline last 2 months . functional change
  in bed, posture, swallow
• Family reluctant for EOL planning, grief

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Anticipatory Care (Cont)

• Intervention/Plan
• Hypernatraemia 169 all else NAD dehydration
• Anticipatory care plan with GP - EOL discussions
  with husband wishes to avoid admission
• Liaised with Geriatrician plan educate
  staff/family to push oral fluids, monitor ues
• Medication review
• Outcome
• Fluid Intake gt2000mls daily maintained
• Health stabilised improved baselines, reduced
  admissions,
• MDT Input SALT, Physio, OAP back in lounge,
  in chair, smiling, weight gain
• Improved quality interaction with family
• Clear anticipatory plan with EOL aims, 6 monthly
  planned reviews
• 1 further admission during pilot shorter LOS

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Pilot Results

• You gave me my father back

• Investment of approx 50k
• 98 patients case managed
• 45.5 reduction in admission rates based on
  2008/09 data
• - admission days 440
• - admission costs 243,146
• Savings assuming same conditions/reasons for
  admission for total care home population in
  Gateshead
• - 6763 bed days
• - 3,730,446

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Patients, Carers and families
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Expanding this across Gateshead

• Care homes trained
• 28/34 Care homes linked to practices
• 6 specialist nurses proving comprehensive
  reviews, care planning, liaising and reactive
  care
• Medicines Management Team
• GHFT Geriatrician
• Laptops
• Key partners- LA, OA Psychiatry

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Specialist Nurses Commissioned
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The Project Group

• Dr Mark Dornan
• Lesley Bainbridge
• Lynne Shaw
• Dr Daniel Cowie
• Dr Louise Crabtree
• Marc Hopkinson

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Any Questions?

• http//gatesheadccg.nhs.uk/about-us/case-studies/